Health inspection·August 12, 2025

F 0584 Level of Harm - Actual harm Residents Affected - Some pneumonitis, atrial fibrillation, and insomnia. R7's MDS dated [DATE] documented a BIMS score of 13, indicating R7 was cognitively intact.On 7/30/25 at 10:52 AM, R7 stated It's plenty hot in here. The main problem is it's hard to sleep at night. It's uncomfortable day and night. The thermometer measured the ambient air temperature in R7's room to be 82.6 degrees F.On 7/30/25 at 11:43 AM, staff were passing noon time meal trays to several residents sitting in the dining room. The thermometer measured the ambient air temperature of the dining room to be 84.5 degrees F.On 7/30/25 at 11:49 AM, the Heating, Ventilation, and Air Conditioning (HVAC) unit farthest from the nurse's station on 300 hall was running but putting out a very small amount of cold air and was dripping condensation onto the floor and had ceiling tiles with greenish brown discoloration surrounding it.On 7/30/25 at 11:51 AM, the HVAC unit closest to the nurse's station on 300 hall was not working.On 7/30/25 at 11:53 AM, the HVAC unit above the nurse's station was not working and had 7 ceiling tiles with greenish brown discoloration.On 7/30/25 at 11:56 AM, the HVAC unit closest to the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:57 AM, the HVAC unit farthest from the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:59 AM, the HVAC unit closest to the nurse's station on 400 hall was not working.On 7/30/25 at 12:01 PM, the HVAC unit farthest from the nurse's station on 400 hall was blowing out a small amount of cold air. On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had asked corporate for 33 PTAC units to replace the older PTAC units in resident rooms and corporate had only sent him 4 PTAC units. V4 said several of the PTAC units in resident rooms had been replaced during the winter of 2024 but the PTAC units that were not replaced could not keep up with cooling resident rooms. V4 said the facility did have portable air conditioners but if too many were plugged in it would pop the breaker and everything plugged into that electrical line would lose power. V4 verified most of the HVAC systems in the facility were not functioning or not functioning well. V4 said he had contacted the HVAC company to come to the facility and fix the HVAC units but was told they would not come to the facility until the facility paid the bill from the last time the HVAC company had been at the facility.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said the air conditioning is a reoccurring theme every summer. V1 said he had done everything he could do but did not have the authority to change the HVAC units. V1 said in December of 2024 he had replaced all the PTAC units in resident rooms that needed changed but the PTAC units that needed replaced now are the older ones that were about 2 years old and are starting to fail. V1 said they needed to be replaced but corporate had only sent the facility 4 new PTAC units. V1 said he had emailed and called corporate several times about the HVAC systems and PTAC units not working but corporate still had not fixed them.On 8/1/25 at 12:14 PM, V7 (Medical Director) said he was aware the facility has had trouble with the HVAC system. V7 said with the temperatures being over 81 degrees F, it would not cause the residents to go into true respiratory failure but it would be more difficult to breathe with the high heat and high humidity. V7 said the combination of comorbidities and being elderly put the residents at high risk for dehydration, heat exhaustion, and heat stroke. V7 stated (V1) is passionate about it and has been trying to get it fixed. V7 said some of the resident rooms were very hot and that was not good. V7 said the last few days had been very hot.On 8/6/25 at 11:40 AM, V6 (Licensed Practical Nurse/ LPN) said the air conditioning had not been working all summer. V6 said over the weekend (8/2/25 and 8/3/25), the HVAC units on the 400 hall were blowing out hot air and they could not shut them off. V6 stated it was miserable in here.The facility's undated Extreme Weather- Heat or Cold policy documented in part . The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate the risk, we rigorously maintain our systems of heating, ventilation and air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Actual harm Residents Affected - Some conditioning and generator. Individuals are prone to heat illness when they remain in hot or humid weather for an extended period. If the facility reaches a heat index/ apparent temperature of 80 (degrees) Fahrenheit implement the following actions and/ or treatments. Move individual(s) to cool area. Utilize electric fans circulate air. Notify Director to ensure measures for air condition repair and resident care are being followed.The facility's December 2016 Hot Weather Plan documented in part .1. Monitoring: a. in the event of a loss of air conditioning, hallway temperatures will be monitored and recorded every hour on the Temperature Monitor Log. d. The administrator or DON should contact the Regional [NAME] President and Regional Nurse Consultant. f. Nursing will assure that each Resident's room has an operational fan. 3. Maintenance Department Response: a. Maintenance staff will be available 24 hours a day during any heat emergencies. Various heating and cooling companies will be utilized as necessary. b. Administrator, Maintenance Supervisor or designee will determine if any of the above providers should be called out. 6. Other: The Department of Health and Senior Services must be notified during serious heat emergencies. This would be defined as. when persistent heat related issues cannot be resolved by the Administrator and/ or Maintenance.On 8/12/25 at 11:40 AM, the website Weather Underground (https://www.wunderground.com/history/monthly/us/il/salem/KMWA/date/2025-7) historical data documents a maximum temperature of 91 degrees F on 7/30/25 with a maximum humidity of 100%.On 8/12/25 at 12:52 PM, the website https://southernillinoisnow.com/2025/07/28/more-than-130-million-people-brace-for-sweltering-conditions-across-most-of-th documented on 7/28/25 at 6:37 AM a report documenting in part .Extreme heat is also expected to continue on Monday and Tuesday in the Midwest, where over the weekend temperatures felt between 97 to 111 degrees from [NAME], Nebraska, up into Minneapolis . Looking ahead to the work week, potentially life-threatening heat and humidity are expected to continue across the eastern half of the country through Wednesday. Major cities including St. Louis, Memphis, [NAME], [NAME], [NAME], and [NAME], Mississippi, are all likely all see actual temperatures in the upper 90s to low 100s. A prolonged heat wave is forecast for those regions as an abundance of tropical moisture settling in is expected to drive the feels-like temperatures up to between 105 to 115 degrees over multiple consecutive days .2. On 8/1/25 at 10:14 AM, V8 (Family Member/Power of Attorney/POA) said she comes to visit R2 every Sunday, and the dining room floor is always dirty and in bad shape when she is in the facility.On 8/1/25 at 1:10 PM, the dining room floor appeared to be dirty with several tiles with blackish brown discoloration. The tiles lining the area where the flooring changes to tile were cracking and uneven with black discoloration on them from wall to wall. Several tiles by the sliding glass door were bubbled and had a blackish brown discoloration. Several tiles located around the kitchen entrance had a large amount of blackish brown discoloration with bubbling and cracking.On 8/1/25 at 1:35 PM, V10 (Housekeeping Supervisor) said the discoloration on the tiles was glue. V10 said the facility had tried to scrape it off but had not been successful. V10 said there was nothing housekeeping could do about the bubbling and cracking tiles.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had the dining room floor professionally stripped and waxed and was told there was nothing more they could do for the floor. V1 said corporate was aware of the dining room flooring.On 8/7/25 at 10:20 AM, V4 (Maintenance Director) said he had started replacing bubbling tiles. V4 said the dining room floor had several layers of tile and as the tile below broke down it would cause the top tiles to bubble and crack. V4 said the only way to keep the top tiles from bubbling and cracking would be to replace the flooring. V4 said he had stripped the floors and had removed a large about of the discoloration. V4 said he was going to put 3 layers of wax on the floor to avoid discoloration but as the lower tiles broke down it would cause the glue to seep up between the top tiles and collect dirt and debris causing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 discoloration.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility. Level of Harm - Actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain a temperature of less than 70 degrees Fahrenheit in the dietary dry storage area in accordance with facility policy. This failure has the potential to affect all 58 residents residing in the facility.Findings include:On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 7/30/25 at 11:08 AM, V5 (Dietary Manager) said the dietary dry storage area did not have a functioning Heating, Ventilation, and Air Conditioning (HVAC) unit and had been very hot since the start of summer 2025. Using the calibrated thermometer, the ambient air temperature in the dietary dry storage area was observed to be 90.6 degrees Fahrenheit.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had notified the HVAC company of the HVAC system not functioning in the dietary dry storage area and was told the HVAC company would not be coming to the facility until the facility paid the bill for the last time the HVAC company had performed work for the facility in December 2024.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had been asking corporate to fix the HVAC system in the dietary dry storage area for 1 year and 1 month.The facility's January 2012 Dry Storage Areas policy documented in part . Dry storage areas will be kept neat, orderly, and in a condition which protects foods in a safe and sanitary manner. 1. Non-perishable foods will be stored in a dry area with temperatures that do not exceed 70 F.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility. Event ID: Facility ID: 145247 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to ensure the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all 58 residents residing in the facility.Findings include:On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had emailed and called corporate several times about the HVAC (Heating, ventilation, and Air Conditioning) units and PTAC (Packaged Terminal Air Conditioner) systems not working but didn't hear anything back from them. V1 said he did not have the authority to change the HVAC units, that was a corporate decision. V1 said he had been asking corporate to fix the HVAC unit in the dietary dry storage area for 1 year and 1 month prior to this investigation. V1 said he had notified corporate of the dining room floors needing to be replaced but had not been given approval to fix them.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had been told by the HVAC company they would not return to the facility to fix the HVAC units until their bill had been paid from December 2024. V4 said he had requested from corporate 33 PTAC units for resident rooms and had only been sent 4 PTAC units. V4 said he was aware there was a room where residents residing that did not have a functioning call light system. V4 said he had called the company that fixes the call lights and had been told the company would not come to the facility until their bill was paid.On 8/6/25 at 11:16 AM, V12 (Regional Director of Operations) said corporate was not aware of any of these issues.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a functioning call light system for 3 (R2, R3, and R4) of 6 residents reviewed for resident call system in the sample of 6.Findings include:R2's Resident Face Sheet documented an admission date of 2/21/18 and included diagnoses of hemiplegia following cerebral infarction, vascular dementia, and need for assistance with personal care. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.R3's Resident Face Sheet documented an admission date of 8/23/24 and included diagnoses of chronic respiratory failure and history of cerebral infarction. R3's MDS dated [DATE] documented a BIMS score of 9, indicating moderate cognitive impairment.R4's Resident Face Sheet documented an admission date of 12/21/23 and included diagnoses of other motor neuron disease, respiratory failure, and chronic pain. R4's MDS dated [DATE] documented a BIMS score of 15, indicating R4 was cognitively intact.On 7/30/25 at 10:20 AM, there were large, loud industrial fans running at both ends of the hall where R2, R3, and R4's reside.On 7/30/25 at 11:08 AM, R2, R3, and R4 were in the same shared room and had hand bells on their over bed tables. R4 stated that R2, R3, and R4 had the hand bells because the call light was not working in their room. R4 said her call light had stopped working about a week prior to this investigation. R3 said her call light had not been working for a couple months prior to this investigation but was unsure of the exact date it stopped working. R3 said she had been told the facility was waiting on parts to fix it. R4 said up until her call light stopped working, she would use her call light if R3 needed something. R2, R3, and R4's call lights were tested and none were noted to be working.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he was aware R2, R3, and R4's call lights were not working. V4 said he had called the company that fixed the facility's call lights and was told they would not come to the facility due to the facility not paying their bill.On 7/30/25 at 12:12 PM, V1 (Former Administrator) said he was not aware the call light company was not coming to fix R2, R3, and R4's call light due to the bill not being paid, and would contact corporate for direction.On 8/6/25 at 10:32 AM, R4 said when the facility has the industrial fans running, R4 has to ring her hand bell for long periods of time because she assumed staff could not hear her bell over the fans.On 8/6/25 at 11:40 AM, V6 (Licensed Practical Nurse/LPN) said when the industrial fans were running, they were so loud staff could barely hear the phone ringing and if staff were down the hall away from R2, R3, and R4's room, staff would not be able to hear their hand bells ringing.On 8/7/25 at 1:20 PM, V7 (Certified Nursing Assistant/CNA) said when the industrial fans were running, there was no way staff could hear R2, R3, and R4's hand bells if staff were down the hall or at the nurse's station. On 8/1/25 at 10:14 AM, V8 (Family Member/Power of Attorney/POA) said she was not sure when R2's call light had stopped working. V8 said she comes to the facility to visit R2 every Sunday and on 7/27/25, V8 saw a hand bell sitting on R2's bedside table. V8 said she had questioned why R2 had a hand bell and was told by staff R2's call light was not working. V8 said the facility was having trouble with their air conditioning and had large industrial fans running. V8 said when the industrial fans were running staff could not hear R2's hand bell ringing.The facility's July 2014 Answering the Call Light policy documented in part .7. Report all defective call lights to the nursing supervisor promptly.On 8/12/25 at 8:52 AM, V9 (Administrator) said she had asked corporate for a functionality of the call light policy and what to do if it wasn't working on 8/8/25 but was told they could not find one. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145247 If continuation sheet Page 7 of 7